Contents
Did you know that dental fear exist?
In the medical context, what we have to acknowledge regarding the patient, whether it’s for therapy or a medical problem, is that they’re already in an altered state of consciousness. They’re already functioning differently than they would normally because they’re anticipatorily anxious. They’re concerned about the intervention or the diagnosis or the message. So they’re already in the beginnings of a sympathetic nervous system driven altered state of consciousness, a sympathetic nervous system trance.
So if the patient already walks in that way, your job is not to try and overlay something that’s already there. Your job is to recognize it, as Erickson would say, ‘utilize what the patient brings you’ and then you work with that. If they’re truly in fight or flight, in blind terror, you modulate that to neutral so you can at least communicate. And then if you’re skillful, you can get that into a parasympathetically driven state, which is conventional hypnosis.
In the medical field you don’t really have time for protracted relaxation based or imagery based inductions (if you’re a hands on physician, an emergency room physician, a paramedic on the street). Depending on the context, you either work with the machine or you work with machine code, but you don’t worry about the operating system that’s being overlaid on top of those basic functions. Therefore, rapid inductions become a whole different ballgame.
Inductions in clinical practice are, as Dr. Gabor Filo would put it, “an asset”. And if you’re doing formal hypnosis with a patient, where there’s an intake process and all sorts of rapport building. What the patient wants is to deal with their problem and you want to get to the crux of the problem, and that’s where rapid inductions are crucial and understanding how they work, when to apply them, and when not to apply them.
Hypnosis, altered states of consciousness, meditation, that’s all parasympathetically driven. Sympathetically driven trances are “fight or flights”. Because if you think about what hypnosis is, you go from the outside, you narrow your focus of attention to the inside, and in a fearful context, your survival mechanism forces you into a narrow and hypervigilant state where the only thing you’re looking for in the environment is something that’s going to be dangerous.
And so when you have either one of these in an imbalance, you have an altered state of consciousness. We often make a mistake when we think that the body doesn’t have an impact on the mind, and yet it has more of an impact than people give it credit for. We’ve come to live in our heads in the 21st century, we forget about the machine, and the machine is run by the autonomic nervous system.
In a normal context, in a walking state, you have the parasympathetic just a little bit more active than the sympathetic to keep it in balance. So, let’s say you’re frightened by something, your sympathetic nervous system jumps the parasympathetic then once the risk or threat is gone, brings it back down. And so there’s always this little bit of parasympathetic overactivity in comparison, and that’s our normal waking state. And then that modulates as necessary.
Now, in our current world, with chronic stress, being a fundamental creature we live with on a daily basis, you’re going to have far more sympathetic drive. And it’s tougher to get the parasympathetic to modulate it down unless you make a concerted effort with some form of technique.
Of 40 years of experience, Dr. Filo has been dealing with patients that have been dentally fearful, anxious and phobic people. Now, as a hypnotist and a clinical hypnodontist, he has noted that there seems to be a relationship between anxiety and hypnosis, though on the surface of it, it may not be apparent.
If we take a quick look at the Oxford Handbook of Hypnosis, they characteristically state that people with diagnosed and defined anxiety disorder, acute stress disorder, posttraumatic stress, dissociated identity, and bulimia, they are all far more hypnotizable than the average person out there. That’s interesting because somebody ends up in a context where they experience something, they don’t get post traumatic stress, the other person does.
And it makes you wonder, is it that factor, that one is more hypnotizable than the other, that there has become this now pathological change in functioning? One of Dr. Filo’s colleagues, Jack Gerschman down in Australia, has done a lot of research over a long time on dental fear, anxiety and phobia. And he states that just like the Oxford Handbook, that there are many psychological disorders that have higher hypnotizability levels.
His research has shown that if you’re a phobic patient, regardless of the phobia, you will be more hypnotizable. And many studies have replicated this, and the relationship improves the ability of treating them successfully with hypnosis. Therefore, if you are phobic and highly hypnotizable, not only the cause may be due to your hypnotizability, but the outcome of successful treatment will also be related to that fact.
And he continues on and he likes to talk about it. And he actually would hope that in the ICD ten and the DSM five, the dental anxieties would be their own subsection as dental anxiety disorders. He himself posits that there’s a causal relationship both to the acquisition and the management of dental phobic disorders.
Dental fear
Fear, as defined by the American Psychological Association, is an intense emotion aroused by something that is imminent. When we think about emotions, we think about feelings. Yet, Rita Carter in her book and others have also described emotions – they’re not feelings, they’re machine coded survival mechanisms. Emotions are a survival mechanism. They happen instantly because if you had to think about it, you wouldn’t survive. And this is where the computer analogy comes in handy beautifully.
You have at the base, the hardware that’s our body, that’s our autonomic nervous system, our brain stem, and all of that other grey goo inside our calvarium. To operate this stuff, you have what is called machine language. In the computer world, this is the true binary system, the one and zero. On top of that, you now have assembly language.
And then the operating systems are built on top of that as an interface for people like you and me who may not know the first thing about a computer other than how to turn it off. In that sense, an emotion is machine code, it’s machine language and it’s the basic functions that keep us alive, autonomic nervous system driven. And in the dental context, particularly talking about dental fear, in the top first two categories are the needle and the sound of the drill.
One more detail to consider is that when a dentist is working in your mouth, they are interfering with the most important organ of communication. The moment you see daylight, you communicate through your mouth. And then it’s now being obturated and obtunded and blocked and irritated and made painful and uncomfortable by this guy who is theoretically helping.
Dental anxiety
If we compare fear and anxiety, fear is short term, identifiable, and imminent. Anxiety is the sign that says there’s a minefield, and if you walk into it, you may explode. It’s future oriented, long term, it’s diffused because you don’t know where the minefield has the mines buried, you just know it’s on the other side of the fence. So anxiety is future termed, living in the future.
And one of the things that tends to happen with anxiety disorders is there’s always a touch of depression. Depression is always living in the past. Fear is in the moment. Anxiety is in the future, which is something to keep in mind as your dental patient is sitting there “doing the pretzel” in the chair, as Dr. Filo calls it, trying to avoid even acknowledging the dentist’s existence.
Anxiety is an emotion which is characterized by feelings. One of the ongoing issues is that once you’re in an anxiety inducing context and your disorder starts, it plays a recursive loop of intrusive thoughts, all tending to be catastrophizing in the future. And they always go in quantum leaps so it’s not a logical next step, it’s the next quantum leap to the most catastrophic outcome possible.
And in dentistry, most patients tend to come into the cabinet from a tooth that abscessed ages ago, but it’s only now that got them to the point to overcome their fear. So it’s becoming less diffuse and more fearful as they come in with their anxiety. Phobias are an irrational fear of something which ultimately causes you to avoid that, unless the fear of dying finally drives the patient through the front door of their dentist.
Dentally anxious people
There are four categories of dental fear displayed in the Seattle system for diagnosing dentally anxious individuals:
1. In the first category, the type one patient got specific fears of drills, needles, blood, smells, whatever they’re known as simple or specific phobias. When they reclassify the diagnostic and statistics manual, they renamed them to be “specific phobias”.
2. Type two is an anxiety about some sort of somatic reaction while being treated. These are fainting, gagging, panic attacks, allergic responses. One of the interesting things, most dental local anesthetics have an amount of epinephrine in them as basal constrictors, so the anesthetic sticks around longer and does its job more profoundly.
Well, people that think they have an allergic reaction to anesthetics, are actually having a sympathetic nervous system rush based on the small amount of epinephrine that’s actually in the anesthetic. But they mistake that, and then they think it’s an allergy, and then they think they’re going to die. The closest diagnostic equivalent would be agoraphobic disorders, without panic and somatic neurotic focus with possible somatic form disorders.
3. Type three patients are the ones with anticipatory anxiety, with other diagnosed anxiety disorders and phobias. So these are folks that already have underlying psychiatric issues. And the dentists just happen to be one in a large collection of anxieties. And what you get is you get a summation of effects. And if you’ve ever seen a general anxiety disorder patient have a full blown anxiety attack in your chair, it’s not very pretty. Also, if you’re not ready to deal with it, it can be as traumatizing to the clinician as it is for the patient.
4. Finally, type four patients are the ones that don’t like dentists, they don’t trust anybody in the context, they’re afraid of all. And these are the socially phobic sorts. And there’s an ego component involved, which is a sense of embarrassment because of the state of their mouths, ‘they know better, but’.
This is the system, it’s been in use probably about 30 years, but in terms of most dentists that deal with phobic patients, they tend to use pharmacological interventions, sedation anesthesia of some sort. We rarely hear these things discussed when they talk about helping anxiety patients.
One understanding of dental fear and anxiety might be through the lens of evolution, which has ensured us mechanisms that secure our survival. In this context, dental anxiety is an evolutionary feature that, like everything else, leads to ‘too much of a good thing is bad’. One of the foremost researchers and Enrico Facco and his crew in Italy are outstanding, address this from a purely dental type clinician’s perspective.
Their approach is from both the machine code and the overlying operating system. From their observations, dental anxiety and pain are the cause of medical emergencies in dental offices. They’re closely related to the fight or flight reaction, which is sympathetic nervous system in overdrive, and that everything has evolved in parallel so that we survive.
Basic emotions are related to survival functions. And here again, if you consider the fact that an emotion is machine coded, it’s there so you can react without thinking about it, which they’ve discovered. Most of their anxiety prone dental patients were unaware of the cause of their anxiety, but it’s instantaneous and automatic because it’s designed to help them survive. Also archaeology has shown that dentistry has been an issue going back to cavemen.
There is a study in nature where a tooth that is 14,000 years old, has a serious lesion and has tool marks on it from somebody having scraped out the decay, so this fear of dentistry has been with us an awful long time.
It’s that machine code that keeps interrupting to ensure your survival. Then there are feelings that are spontaneous and are appropriate to the moment or mostly appropriate to the moment. And then many people live their lives moving from one emotional trance to another so that they’re sort of caught in this basic functioning that doesn’t necessarily work through other patterns. A dental phobe is definitely stuck.
The hypnotherapist’s (or the hypnodontist’s) job is not to try and superimpose another trans, but to recognize the one that’s there and perhaps de-hypnotize, so that you can now start communicating and fixing whatever the problem is. In hypnotic trance there is a narrowed focus of attention, there’s a decrease in distractibility and an increase in absorption.